Adequate control of pain, especially at the end of life, is a key issue in modern medical care. Increasingly doctors, nurses, patients, family members and advocates realize that death need not be physically painful. The most recent demonstration of that consensus among medical care providers comes from the Oregon Board of Medical Examiners.

Dr. Paul A. Bilder was disciplined last month by the state Board for failing to provide adequate pain control for six of his patients. This may be the first time an American doctor has ever been disciplined for providing too little medication, rather than too much; disciplinary proceedings for overuse of medication are relatively commonplace in medicine.

Dr. Bilder, a pulmonary disease specialist, agreed to the imposition of disciplinary measures rather than undergo a contested proceeding. He acknowledged that his undertreatment of pain “showed unprofessional or dishonorable conduct and gross or repeated acts of negligence. He will be required to complete a one-year peer-review program, visit a psychiatrist regularly and take a course on physician-patient communication.

According to the Board of Medical Examiners, Dr. Bilder failed to provide adequate pain control for at least six of his patients. Specifically, he:

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Treated an elderly man who was dying of cancer and in pain with “substantially inadequate amounts of pain medication,” contrary to a hospice nurse’s request for stronger pain drugs and anti-anxiety medication. He also refused a hospice nurse’s request to give the man a urinary catheter. Dr. Bilder told the board he thought the catheter would cause infection. The patient died of his cancer three weeks later.

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Ordered removal of a urinary catheter from a dying and incontinent cancer patient, against the wishes of the patient and family. Dr. Bilder told the hospice nurse to use diapers instead. Dr. Bilder ordered a small fraction of the pain medication the hospice nurse suggested, and Tylenol for high fever. He believed the nurse’s request for additional pain drugs was excessive. The patient died that evening.

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Stopped giving sedatives and pain medication to a 35-year-old woman with pulmonary disease while she was on a mechanical ventilator at Mercy Medical Center in Roseburg. He ordered a paralytic agent, which relaxes the breathing muscles to accommodate the breathing tube, without the use of sedatives. (Sedatives are often used to combat panic from having the breathing tube in the throat.)

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Refused a nurse’s request to give morphine to treat anxiety in a 63-year-old woman with pulmonary disease and diabetes who was put on a ventilator at Mercy Medical Center because of acute respiratory failure.

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Refused morphine or other pain medication for a hospitalized 82-year-old patient with congestive heart failure. The patient told a nurse, “I just can’t breathe, and I’m getting tired.” The patient became increasingly agitated, and his breathing and heart rates increased.

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Failed to give a 33-year-old pneumonia patient narcotic painkillers or anxiety medication while installing a breathing tube through the patient’s nose. The medical staff made multiple attempts to get the tube in, causing the patient’s nose to bleed. The staff had to restrain the patient to complete the procedure.

The issue of adequate pain control was raised by a national study, published in 1989, showing that more than half of seriously ill and hospitalized patients die in pain. Recently the debate over physician-assisted suicide has pushed doctors to provide better pain control in hopes that patients will be dissuaded from wanting to end their lives.